Trisomy 21 or what many people know it as is Down syndrome which is a condition that affects one out of every 800-1,000 births. This is the result of an extra chromosome of the twenty first group. With this special group of individuals becoming increasingly active in the community, work and school need to also have their dental care attended to. With this condition many dental concerns come into place which are the following, but not limited: MPV (mitral valve prolapse), they have lower number of T-cells (which weakens their immune system and are more prone to infections including periodontal disease), upper respiratory disease (can further aggravate their mouth breathing), xerostomia, and fissuring of the tongue. Including with these conditions they have a greater incidence of apthous ulcers, oral candida infections, and ANUG. They also have a higher incidence of epilepsy, diabetes, leukemia, and hypothyroidism.
In addition, many of the patients generally have hypotonia which is a reduced degree of muscle tone and affects the musculature of the head and the oral cavity as well as the large skeletal muscles. There is an imbalance of forces between the lips and cheeks and with the tongue and the tongue being the greatest of the two. This is the correlation between the tongue and the open bite. Due to the loss of muscle tone, the chewing is less effective and there is less cleansing of the teeth. Another factor affecting is a theory in which ligamentous laxity is seen throughout the body causing hyperflexibility of the joints and it is also speculated that this can affect the ligaments of the teeth. This is a condition that can affect 10-20% of this population and can affect the mobility of the C1 and C2 cervical vertebrae which can be of concern when reclining the patient back in the dental chair (to avoid potential harm to the spinal cord).
The main focus for this special group of patients is their home oral care. The severity of their condition will dictate the clinician how to, how much, and what hygiene products will be appropriate for the individual patient or the care provider. Many of these special groups of patients have facial bone arrangement in which allows for pocketing food in the cheeks, habitual tongue movements, swallowing habits or mouth breathing. All of the mentioned conditions play a very important role in constructing the ideal home care plan for that individual patient.
II. Medical history
Patient is 8 years of age. His mother states that chief complaint is, "His gums bleed alot and teeth are discolored". Pt.'s gums bleed when mom brushes them, pt. has sensitivity to cold temperatures, patient grinds teeth, patient gets recurrent apthous ulcers. Patient has allergy induced asthma, patient was hospitalized for bronchitis when he was 6 years of age. He was also diagnosed with Mitral Valve Prolapse at 4 years old and was given antibiotic prophylactic regimen for any future dental appointments. Patient is farsighted and wears glasses for this. Pt. occasionally suffers from gastroenteritis symptoms. Patient's vaccinations are current. Patient is currently receives albuterol by nebulizer as needed for asthma.
III. Gingival description (refer to photo above)
Free: Gen. erythematous, gen. scalloped with localized loss of architecture, gen. edematous, gen. smooth.
Attached: Gen. pink, gen. firmly bound, gen. smooth with loss of stippling
IV. Assessment findings:
Salivary Flow: Inadequate
MBI: 85%, BOP: 95%
PI: 100%
Recession: No areas noted, but Down's syndrome patients may typically present with these findings
Furcations: No areas noted, but Down's syndrome patients may typically present with these findings
Mobility: (+) #'s 24, 25
Fremitus: (+) #'s 8, 9
Mucogingival defects: None
Attachment loss: None
Angles Class: Angles Class III with anterior end to end bite
ADA I, AAP Generalized moderate gingivitis due to plaque and calculus, modified by systemic factors. RCC code: light
V. OHI:
Motivational Theory:
Social Cognitive Theory bases the patient's environmental factor as a major influence on their oral health. Since it is based on the psychosocial factors, the parent/caregiver must implement oral health home care. Interactive care, as well as modeling, should be displayed between the patient and parent because mental retardation may range from normal to severe. It is encouraged to initiate this in the patient's daily activities.
The patient would most likely not present the capabilities or dexterity to floss or brush properly. Therefore, the parent/caregiver plays in important role in maintaining their oral health daily.
Educate caregiver on patient's risk/prevalence of periodontal disease.
Electronic toothbrush (based on patient's compliance)
Importance of flossing- patient's malocclusion increases risks for plaque retention
VI. Treatment Plan Appointments:
Appt #1:
RMH
Medical consult for patient's Mitral Valve Prolapse
Appt #2:
Pt. must take antibiotic regimen 1 hour prior to appointment
Depending on patient's compliance radiographs may be taken- Pedo FMX
DDS exam
PI
OHI- to caregiver and patient
Nutritional counseling
Appt #3:
2nd check in
Full mouth scale or deplaque (in the absence of calculus)
ApF fl. tx (foam) for 4 minutes (based on patient's compliance)
OHI-to caregiver and patient
Review patient's nutritional habits with parent or caregiver
Appt #4:
Restorative treatment or evaluation for caries
3 month recall
VII. Additional treatment:
Nutritional Counseling to parent/caregiver:
Educate parent or caregiver to reduce fermentable carbohydrates
Excessive sugars or acidic foods
Importance of routine maintenance
Suggest automatic toothbrush if patient is compliant
At-home fluoride rinses and toothpaste
Stress importance of flossing patient's teeth
Avoid alcohol-based rinses to prevent xerostomia
Avoid reclining patient to supine positions to avoid potential harm to the patient's back
Recommend tongue brushing to prevent halitosis with prominent fissured tongue
Consider night guard (based on patient's compliance) for patient's bruxism
Carefully monitor wound-healing
Educate caregiver on etiology and recurrence of apthous ulcers
Multiple Choice Questions:
1. A common oral finding in down syndrome patients are: a. Microdontia b. Enlarged tonsils due to mouth breathing c. Macroglossia d. Fissured tongue e. All the above
2. Adults with Down's Syndrome age prematurley. Many over the age of 40 develop an Alzheimer's-like dementia with pathologic brain changes similar to those of Alzheimer's disease. a. Both statements are true. b. Both statements are false. c. First statement is true, second statement is false. d. First statement is false, second statement is true. 3. Periodontal disease in Down's Syndrome patients is predominant: a. Due to decreased immune deficiency. b. Due to leukocyte function being impaired by chemotaxis and phagocytosis. c. Due to patient's age playing a factor in the destruction of bone. d. Due to patient's abnormal toungue thrust from macroglossia.
4. Which angles class is most common in Down's Syndrome? a. Class I b. Class II c. Class III 5. Necrotizing ulceratie gingivitis (NUG), superimposed over gingivitis or periodontitis, has been found more in patients with down syndrome in those with other types of mental retardation. A. True B. False 6. Teeth #s 8, 9, 24 and 25 all exhibit: a. Fluorosis b. Microdontia c. Macrodontia d. Amelogenesis imperfecta 7. The maxillary lateral incisors pictured most likely are displaying: a. Congenitally missing due to patient's condition. b. Delayed in eruption due to Down's Syndrome. c. Showing signs of attrition due to patients occlusion. d. Erosion due to acidic environment. e. both a and b 8. A clinician should suggest what type of Oral hygiene instruction for this patient? a. C-flossing method b. Bass brushing technique c. Fones brushing technique 9. What oral hygiene product would be beneficial for this patient? a. Glide floss b. Rubber tip stimulator. c. Interproximal aid with a large handle. d. Listerine mouth wash.
10. As a clinician, special precautions are considered in which of the following due to the patient's condition: a. Sitting position. b. Fluid suctioning. c. Increased gag reflex d. All the above
Case #6 Down's Syndrome
I. Overview of Down's Syndrome:
Trisomy 21 or what many people know it as is Down syndrome which is a condition that affects one out of every 800-1,000 births. This is the result of an extra chromosome of the twenty first group. With this special group of individuals becoming increasingly active in the community, work and school need to also have their dental care attended to. With this condition many dental concerns come into place which are the following, but not limited: MPV (mitral valve prolapse), they have lower number of T-cells (which weakens their immune system and are more prone to infections including periodontal disease), upper respiratory disease (can further aggravate their mouth breathing), xerostomia, and fissuring of the tongue. Including with these conditions they have a greater incidence of apthous ulcers, oral candida infections, and ANUG. They also have a higher incidence of epilepsy, diabetes, leukemia, and hypothyroidism.
In addition, many of the patients generally have hypotonia which is a reduced degree of muscle tone and affects the musculature of the head and the oral cavity as well as the large skeletal muscles. There is an imbalance of forces between the lips and cheeks and with the tongue and the tongue being the greatest of the two. This is the correlation between the tongue and the open bite. Due to the loss of muscle tone, the chewing is less effective and there is less cleansing of the teeth. Another factor affecting is a theory in which ligamentous laxity is seen throughout the body causing hyperflexibility of the joints and it is also speculated that this can affect the ligaments of the teeth. This is a condition that can affect 10-20% of this population and can affect the mobility of the C1 and C2 cervical vertebrae which can be of concern when reclining the patient back in the dental chair (to avoid potential harm to the spinal cord).
The main focus for this special group of patients is their home oral care. The severity of their condition will dictate the clinician how to, how much, and what hygiene products will be appropriate for the individual patient or the care provider. Many of these special groups of patients have facial bone arrangement in which allows for pocketing food in the cheeks, habitual tongue movements, swallowing habits or mouth breathing. All of the mentioned conditions play a very important role in constructing the ideal home care plan for that individual patient.
II. Medical history
Patient is 8 years of age. His mother states that chief complaint is, "His gums bleed alot and teeth are discolored". Pt.'s gums bleed when mom brushes them, pt. has sensitivity to cold temperatures, patient grinds teeth, patient gets recurrent apthous ulcers. Patient has allergy induced asthma, patient was hospitalized for bronchitis when he was 6 years of age. He was also diagnosed with Mitral Valve Prolapse at 4 years old and was given antibiotic prophylactic regimen for any future dental appointments. Patient is farsighted and wears glasses for this. Pt. occasionally suffers from gastroenteritis symptoms. Patient's vaccinations are current. Patient is currently receives albuterol by nebulizer as needed for asthma.III. Gingival description (refer to photo above)
Free: Gen. erythematous, gen. scalloped with localized loss of architecture, gen. edematous, gen. smooth.
Attached: Gen. pink, gen. firmly bound, gen. smooth with loss of stippling
IV. Assessment findings:
V. OHI:VI. Treatment Plan Appointments:
Appt #1:Appt #2:
Appt #3:
Appt #4:
VII. Additional treatment:
Multiple Choice Questions:
1. A common oral finding in down syndrome patients are:a. Microdontia
b. Enlarged tonsils due to mouth breathing
c. Macroglossia
d. Fissured tongue
e. All the above
2. Adults with Down's Syndrome age prematurley. Many over the age of 40 develop an Alzheimer's-like dementia with pathologic brain changes similar to those of Alzheimer's disease.
a. Both statements are true.
b. Both statements are false.
c. First statement is true, second statement is false.
d. First statement is false, second statement is true.
3. Periodontal disease in Down's Syndrome patients is predominant:
a. Due to decreased immune deficiency.
b. Due to leukocyte function being impaired by chemotaxis and phagocytosis.
c. Due to patient's age playing a factor in the destruction of bone.
d. Due to patient's abnormal toungue thrust from macroglossia.
4. Which angles class is most common in Down's Syndrome?
a. Class I
b. Class II
c. Class III
5. Necrotizing ulceratie gingivitis (NUG), superimposed over gingivitis or periodontitis, has been found more in patients with down syndrome in those with other types of mental retardation.
A. True
B. False
6. Teeth #s 8, 9, 24 and 25 all exhibit:
a. Fluorosis
b. Microdontia
c. Macrodontia
d. Amelogenesis imperfecta
7. The maxillary lateral incisors pictured most likely are displaying:
a. Congenitally missing due to patient's condition.
b. Delayed in eruption due to Down's Syndrome.
c. Showing signs of attrition due to patients occlusion.
d. Erosion due to acidic environment.
e. both a and b
8. A clinician should suggest what type of Oral hygiene instruction for this patient?
a. C-flossing method
b. Bass brushing technique
c. Fones brushing technique
9. What oral hygiene product would be beneficial for this patient?
a. Glide floss
b. Rubber tip stimulator.
c. Interproximal aid with a large handle.
d. Listerine mouth wash.
10. As a clinician, special precautions are considered in which of the following due to the patient's condition:
a. Sitting position.
b. Fluid suctioning.
c. Increased gag reflex
d. All the above
Multiple choice questions
Answer Page